Provider Demographics
NPI:1225236383
Name:MORRILL, SHANNON SUZANNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:SUZANNE
Last Name:MORRILL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6273
Mailing Address - Country:US
Mailing Address - Phone:208-381-5180
Mailing Address - Fax:
Practice Address - Street 1:305 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6273
Practice Address - Country:US
Practice Address - Phone:208-381-5180
Practice Address - Fax:208-381-5190
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-727363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA-727OtherSTATE LICENSE NUMBER
IDPA-727OtherSTATE LICENSE NUMBER